Сauses of Dizziness in Patients with Suspected Stroke

Background Acute dizziness may be the only symptom of stroke. Prevalence of this disease among patients with isolated dizziness differs significantly and depends on study design, inclusion criteria and diagnostic methods. In available investigations, we did not find any prospective studies where magnetic resonance imaging, positional maneuvers, and Halmagyi-Curthoys test had been used to clarify a pattern of diseases with isolated acute dizziness and suspected stroke.

Aim of study To clarify the pattern of the causes of dizziness in patients with suspected acute stroke.

Material and methods We examined 160 patients admitted to N.V. Sklifosovsky Research Institute for Emergency Medicine with suspected stroke and single or underlying complaint of dizziness. All patients were examined with assessment of neurological status, Dix-Hollpike and Pagnini-McClure maneuvers, HalmagyiCurthoys test, triplex scans of brachiocephalic arteries, transthoracic echocardiography, computed tomography (CT) and magnetic resonance imaging (MRI) of the brain with magnetic field strength 1.5 T. MRI of the brain was performed in patients without evidence of stroke by CT and in patients with stroke of undetermined etiology according to the TOAST classification.

Results In 16 patients (10%), the cause of dizziness was a disease of the brain: ischemic stroke (n=14 (88%)), hemorrhage (n=1 (6%)), transient ischemic attack (TIA) of posterior circulation (n=1 (6%)). In 70.6% patients (n=113), the dizziness was associated with peripheral vestibulopathy: benign paroxysmal positional vertigo (n=85 (75%)), vestibular neuritis (n=19 (17%)), Meniere’s disease (n=7 (6%)), labyrinthitis (n=2 (1,3%)). In 6.9% patients (n=11), the cause of dizziness was hypertensive encephalopathy, 1.9% of patients (n=3) had heart rhythm disturbance, 9.4% of patients (n=15) had psychogenic dizziness, 0.6% of patients (n=1) had demyelinating disease, and 0.6% of patients (n=1) had hemic hypoxia associated with iron deficiency anemia.

Conclusion In 70.6% patients with acute dizziness, admitted to hospital with a suspected stroke, peripheral vestibulopathy was revealed. Only 10% of patients had a stroke as a cause of dizziness.

1. WHO methods and data sources for country-level causes of death 2000– 2015. Department of Information, Evidence and Research WHO, Geneva. 2017.

2. Zhdanova S.G., Petrikov S.S., Ramazanov G.R., et al. Сerebral Infarction as the First Manifestation of Erythremia. Russian Sklifosovsky Journal Emergency Medical Care. 2016; (1): 66–69. (In Russian).

3. Krylov V.V., Volodyukhin M.Yu. Organization of interventional surgery for patients with acute ischemic stroke. Neyrokhirurgiya. 2017; (2): 60–65. (In Russian).

4. Bonita R., Mendis S., Truelsen T., et al. The Global Stroke Initiative. The Lancet Neurology. 2004; 3 (7): 391–393. PMID: 15207791. DOI: 10.1016/S1474-4422(04)00800-2.

5. Cnyrim C.D., Newman-Toker D.E., Karch C., et al. Bedside differentiation of vestibular neuritis from central ‘‘vestibular pseudoneuritis’’. J Neurol Neurosurg Psychiatry. 2008; 79 (4): 458–460. DOI:10.1136/jnnp.2007.123596.

6. Norrving B.,Magnusson M., Holtis S. Isolated acute vertigo in the elderly; vestibular or vascular disease? Acta Neurol Scand. 1995; 91(1): 43–48. PMID: 7732773.

7. Lee H., Sohn S.-I., Cho Y.-W., et al. Cerebellar infarction presenting isolated vertigo: frequency and vascular topographical patterns. Neurology. 2006; 67(7): 1178–1183. PMID: 17030749. DOI:10.1212/01.wnl.0000238500.02302.b4.

8. Kerber K.A., Zahuranec D.B. Brown D.L., et al. Stroke Risk after Nonstroke Emergency Department Dizziness Presentations: A Population-Based Cohort Study. Ann Neurol. 2014; 75 (6): 899–907. PMID:24788511. PMCID: PMC4286199. DOI:10.1002/ana.24172.

9. Kerber K.A., Brown D.L.,Lisabeth L.D., et al. Stroke Among Patients Whith Dizziness, Vertigo, and Imbalance in the Emergency Department: a population based study. Stroke. 2006; 37 (10): 2484–2487. DOI:10.1161/01.STR.0000240329.48263.0d.

10. Newman-Toker D.E., Hsieh Y-.H., Camargo C.A.Jr., et al. Spectrum of dizziness visits to US emergency departments: cross-sectional analysis from a nationally representative sample. Mayo Clin Proc. 2008; 83(7): 765–775. PMID: 18613993. PMCID: PMC3536475. DOI: 10.4065/83.7.765.

11. Paul N.L., Simoni M., Rothwell P.M. Transient isolated brainstem symptoms preceding posterior circulation stroke: a populationbased study. Lancet Neurol. 2013; 12(1):65–71. PMID: 23206553. PMCID: PMC3530272. DOI: 10.1016/S1474-4422(12)70299-5.

12. Tarnutzer A.A., Berkowitz A.L., Robinson K.A., et al. Does my dizzy patient have a stroke? A systematic review of bedside diagnosis in acute vestibular syndrome. CMAJ. 2011; 183(9): 571–592. PMID: 21576300. PMCID: PMC3114934. DOI: 10.1503/cmaj.100174.

13. Saber Tehrani A.S., Kattah J.C., Mantokoudis F.G., et al. Small strokes causing severe vertigo Frequency of false-negative MRIs and nonlacunar mechanisms. Neurology. 2014; 83(2): 169–173. PMID: 24920847. PMCID: PMC4117176. DOI: 10.1212/WNL.0000000000000573.

14. Kattah J.C., Talkad A.V., Wang D.Z., et al. H.I.N.T.S. to Diagnose Stroke in the Acute Vestibular Syndrome. Stroke. 2009; 40(11): 3504–3510. DOI: 10.1161/STROKEAHA.109.551234.

15. Navi B.B., Kamel H., Shah M.P. Rate and Predictors of Serious Neurologic Causes of Dizziness in the Emergency Department. Mayo Clin Proc. 2012; 87(11): 1080–1088. PMID: 23063099. PMCID: PMC3541873. DOI:10.1016/j.mayocp.2012.05.023.

16. Atzema C.L., Grewal K., Lu H., et al. Outcomes Among Patients Discharged From the Emergency Department With a Diagnosis of Peripheral Vertigo. Ann Neurol. 2016; 79(1): 32–34. PMID: 26385410. DOI:10.1002/ana.24521.

17. Hotson J.R. Baloh R.W. Acute vestibular syndrome. N Eng J Med. 1998; 339(10): 680–685. PMID: 9725927. DOI:10.1056/NEJM199809033391007.

18. Abdulina O.V. Frequency, causes, differential diagnosis, treatment and prognosis of acute vestibular dizziness in emergency neurology: Cand. med. sci. diss. Moscow, 2007. 92 p.